Healthcare Provider Details

I. General information

NPI: 1346309531
Provider Name (Legal Business Name): KIM NGUYEN TIBALDI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 OLD SHORT HILLS RD
LIVINGSTON NJ
07039-5672
US

IV. Provider business mailing address

94 OLD SHORT HILLS RD EAST WING SUITE 305
LIVINGSTON NJ
07039-5672
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-5065
  • Fax:
Mailing address:
  • Phone: 973-322-5065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301083840
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA08456300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: